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There are few sights quite so unsettling for governments — and occasionally quite so useful — as Legislature lawns thronged with angry, sign-waving, white-lab-coated doctors.

It’s the sort of thing — clashes between governments and physicians, the latest outbreak occurring now in Ontario — that seems to offend the socio-political laws of nature.

Usually, such spaces are the marshalling grounds for society’s underdogs and long-suffering.

When it’s the well-educated and affluent, however, who are moved to public outrage of a sort their class normally deems unseemly, at a venue where there’s no reserved parking, it’s a sure sign the times are those of either epic social change or extraordinary economic challenge.

In Ontario, where the deficit is running a feverish $15 billion or so, check option B.

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Unhappy doctors generate the sort of uncertainty that makes citizens (i.e. voters) a little queasy — two large, powerful institutions at odds, putting at risk the very service on which people most depend and value, and a system by which many Canadians still define themselves.

Any system that’s said, after all, to have “a father” — and medicare in Canada is said to have several — is not your normal public service. Who, let’s face it, claims paternity for the post office or prisons?

It speaks thunderous volumes that when the CBC ran a contest a few years back to name the greatest Canadian, it wasn’t a comic, industrialist or even a hockey player who won. It was Tommy Douglas, the foremost of the aforementioned sires of medicare.

It was in Douglas’s Saskatchewan that the seeds of medicare were planted and in which the mother of all Canadian doctors’ strikes — a confrontation called “Saskatchewan’s civil war” — occurred.

For decades, that province had experimented with health schemes whereby the quality and alacrity of medical attention did not depend on wealth.

It was no easy task. In British Columbia, the provincial government had passed a Health Insurance Act in the mid-1930s, but this was essentially neutered by the medical profession.

In 1944, Douglas was elected in Saskatchewan on a promise to set up medical, dental and hospital services available to all regardless of ability to pay. It wasn’t until 1959 that he announced the introduction of medicare in the province. It was immediately opposed by the medical profession and others.

The rhetoric
was familiar; complaints from the one side about “arbitrary power” and “dictatorships” and the potential stampede of MDs for the borders; from the other, about doctors more concerned with their fees than their patients.

The Saskatchewan Medical Association raised a considerable war chest from its members, was supported by the Canadian Medical Association, and in the 1960 provincial election ran a vigorous campaign urging defeat of the as-yet-to-be-crowned greatest Canadian.

It should have been a cautionary tale for doctors that, come the vote, the Co-operative Commonwealth Federation increased its majority.

In 1961, Douglas left Saskatchewan for Ottawa and leadership of the new NDP. When his medicare legislation was proclaimed, doctors in Saskatchewan went on strike and the province’s civil war raged. A clergyman said: “This thing may break into violence and bloodshed any day now.” The province provided medical services by flying in British doctors.

Twenty-three days later, the strike ended with the signing of an agreement that, among other things, allowed doctors to extra-bill (that is, to charge above the rates reimbursed by the province) if they worked outside the system.

As historians would record, medicare was an idea whose time had come. Success having many fathers (and occasionally even a mother), its provenance was later attributed to Douglas, his successor as Saskatchewan premier Woodrow Lloyd, who endured through the doctors’ strike, John Diefenbaker for appointing a royal commission to investigate a national version, Lester Pearson for its introduction, and Judy LaMarsh, Walter Gordon and other less-famous progressives who fought for it in cabinet.

Add to the list, of course, Emmett Hall, the prairie populist and later Supreme Court justice who chaired Diefenbaker’s royal commission and called doctors’ claims that medicare amounted to their conscription by the state “scare headlines” and “plain nonsense.”

Hall’s report in 1964 essentially muted the opponents of medicare. And since 1971, every province has had a health-care insurance plan — the fee schedule usually set through negotiations between the provincial government and provincial medical association.

In the half-century
that has followed, there have been doctors’ strikes, usually as brief as a day or two, in several provinces. Just as there’s been endless fine-tuning of fee schedules and the range of insured services.

Until 1984, all provinces allowed doctors to extra-bill, though only a minority of physicians usually did so. The introduction of the Canada Health Act in 1984 by the Trudeau government was, among other things, intended to end extra-billing, and provided provinces with a monetary incentive to ban the practice.

The longest physicians’ strike in Canada occurred in Ontario in 1986, when the Ontario Medical Association called a work stoppage to protest the new Liberal government’s ban on extra-billing.

Premier David Peterson’s minority government had made that commitment as part of a two-year accord with the NDP to oust the long-running Progressive Conservative regime.

Peterson’s attorney general, the late Ian Scott, said he had always regarded extra-billing as a step toward an American-style system in which the affluent received a different standard of care than the less well-off. He later wrote that he would have left the government had it backed down on its commitment.

Which is not to say that fulfilling it was easy. In his memoirs, Scott recalled meeting Dr. Phillip Berger, a Toronto physician who supported the government’s position. Berger said he’d been getting death threats on his home phone.

“I just laughed and said, ‘Oh, that’s nothing. I get those all the time,’ ” Scott said.

In May 1986, thousands of doctors took to the Queen’s Park lawns to protest, brandishing placards rather than prescription pads, signs that read “We’re doctors, not civil servants,” “Down with Socialism,” and “If you like the Post Office, you’ll love state-controlled medicine.”

In his memoirs, Scott made some observations about this that are perhaps germane to the current dispute in Ontario.

“I think that the leaders of the OMA made two basic miscalculations,” Scott wrote. “First, they thought that the public had a basic sympathy for doctors, and that public opinion would be on their side.

“But the public perception of doctors had shifted, from the kind of small-town reverence expressed in Norman Rockwell’s Saturday Evening Post covers, to one that saw doctors fighting to preserve a position of economic privilege. Second, the doctors seriously underestimated our determination as a government not to yield on a point of principle.”

They are likely
also part of the calculation of the current Liberal government of Premier Dalton McGuinty.

Last week, Health Minister Deb Matthews announced 37 changes to the Ontario Health Insurance Plan fee schedule that would save almost $340 million this year. The changes chiefly affect the fees paid cardiologists, radiologists and ophthalmologists — specialties in which technological advance has significantly reduced the time involved in providing certain services.

“Our doctors are the best paid in Canada,” she said. “Instead of another raise for doctors, we need a real wage freeze so we can invest in (more community care for families and home care for seniors). . . I was left with no choice.”

In that comment, in framing the matter as a dispute about MDs’ money vs. the Average (Wo)man’s welfare, she essentially echoed Scott’s two key points.

One, that doctors in Ontario are not seen as the avuncular, house-calling figures of Rockwell, but a very comfortable part of what is these days known — especially to those who have been through the economic wringer of recession and restructuring — as “the 1 per cent.”

Two, that the government is determined not to yield — less (as Scott was) on a matter of principle than on the unforgiving point of dollars and cents.

The premier and his government seem determined to face up to a daunting fiscal challenge, and the need to address soaring health costs in the face of the increased demands of an aging population.

He probably figures his populist bona fides will be enhanced by sharing the pain and shifting money from the pockets of the well-to-do to other needs.

So the OMA’s message during this battle will almost certainly be about process — the offensively arbitrary measure of the government — and the risks raised by sour relations between the two sides.

It will also try to place itself on the side of patients by expressing concern for issues of health-care quality and access. And there will be inevitable reference to the clarion call of doctoring jobs elsewhere.

In all, the state of affairs in the Ontario Health Ministry — true at all times, but especially during times of doctor strife — might best have been summed up by Michael Decter, a former deputy minister of health in Bob Rae’s NDP government in Ontario, in an anecdote in his book
Tales From the Backroom
.

In it, Decter recalled that his minister, Frances Lankin, once sat next to Russell King, who had for almost 10 years been health minister in New Brunswick.

“I used to have the best job in Canadian health care,” King reportedly said.

Lankin, knowing he had been a physician, replied: “You mean being a family doctor?”

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